Only one out of five victims of sexual violence will receive trauma counselling they are entitled to at a designated government hospital and clinic in South Africa, a new study by Doctors Without Borders (MSF) has found.

MSF estimates that half of these health facilities — mostly hospitals — don’t offer counselling services to child survivors of rape, who potentially represent up to half of all survivors.

The study evaluated 265 public facilities that provide medical and psychological care to survivors of sexual violence. Only half of these facilities responded to the survey, and nearly a third of these declined to respond, stating that they did not have permission from the Department of Health to participate. A further 14% could not be reached because their telephone lines didn’t work and another 14% delayed responding to the survey by asking to be called at another time — and ultimately, did not respond by the time the survey was completed. Thuthuzela Care Centres, government’s ‘one stop’ rape care services, make up 55 of all these facilities.

Researchers conducted telephonic interviews during September and October, where each facility was called at least five times. A third of these healthcare facilities have no counselling services for patients who have experienced sexual violence in the past, according to the study that was launched on Wednesday in Johannesburg.

Three quarters of the facilities don’t offer counselling services around the clock, says Yolanda Hanning, an MSF psychologist working in North West Province. “The government’s current response focuses overly on the medico-legal requirements for prosecution, and needs to more adequately address the holistic health needs of survivors,” says Hanning.

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Mental health of survivors takes a back seat

Constance Mlotshwa* thought of killing herself after she was raped in early November. She went to a provincial hospital in North West to see a psychologist. But instead, she was made to sleep in a metal chair overnight while waiting for a bed.

“I thought if I can just gulp a box of rat poison I’ll go and everyone will be happy because I am broken and there is nothing anyone can do to help,” she told MSF.

Earlier in November, President Cyril Ramaphosa announced at Presidential Gender-Based Violence and Femicide Summit that government will fund counselling services at Thuthuzela Care Centres if the need arises. For years, these facilities have been on the brink of shutting down due to lack of funding.

“This is one of the biggest victories because services for rape survivors that these organisations are providing are absolutely essential. At the moment we’re worried about what will happen to the centres because the
not be able to do this on their own,” Sharon Kouta told Health-e News after Ramaphosa’s announcement.

Kouta is a gender-based violence specialist at the Networking HIV and AIDS Community of Southern Africa (NACOSA).

There is very little research on how sexual assault affects the mental health of survivors in South Africa. However, a 2015 survey conducted by MSF among 800 women between the ages of 18-49 years in Rustenburg found that a quarter of these women had been raped in their lifetime. In a third of cases of women who had a major depressive disorder, this could be attributed to rape and intimate partner violence. Rape survivors are more likely to have depression or anxiety. A 2016 study published in the Journal of Forensic and Legal Medicine found that half of about 7,400 rape survivors over the age of 16 in the United Kingdom suffered from anxiety, depression or other mental health issues.

Incidents such as Mlotshwa’s are far too common, says Hanning: “Depression and PTSD are common chronic mental health disorders faced by survivors of sexual violence. The lack of response to the basic human rights of mental health patients that are admitted to state hospitals, continues to reflect the undermining of mental illness as a chronic condition that warrants an emergency response.”

Children who have been sexually violated face an even more dire situation than adults. The report found that there are no counselling services for children in almost half of the surveyed government facilities. About 60% did not have a “child-friendly space”, with toys, a corner to play or equipment for play therapy. More than a third (35%) of school children interviewed for a 2018 study published in The Lancet reported they had been sexually abused at some point in their lives.

Dial *134*334# to access a free and anonymous list of services in five languages for survivors of sexual violence, or visit our map to view and rate facilities across the country

Accessing mental healthcare is a “lottery” for rape survivors

Together with the Department of Health, MSF runs four community health Kgomotso Care Centres (KCC) that provide medical and psychological services to sexual violence survivors around Rustenburg, in the Bojanala Platinum District. These centres are similar to government’s one-stop rape services.

“After my rape I was thinking about suicide. I felt useless. I told myself these people destroyed me in and out, maybe if I go my gran will take care of my kids,” Bridget Monegi told researchers. “But since I’ve come here [to Letlhabile KCC] for counselling everything’s changed. I go to work every day, I smile with people, although it’s hard when I think about it. It’s very traumatising.”

The study also found that 49% of facilities surveyed reported that counselling was done by a lay counsellor.  Only a quarter of the facilities were staffed with a registered counsellor.

As sexual violence often leads to serious psychiatric problems, such as PTSD or major depression, the study notes that it is unlikely that a lay counsellor can adequately address such issues in their entirety.

“From operational experience, we believe a registered counsellor is a more capable cadre when attending to the mental health needs of survivors who present at clinics,” says Dr Amir Shroufi, Medical Coordinator for MSF in South Africa.

MSF is calling on government to ensure that all 265 national facilities designated to provide emergency services for sexual violence victims are equipped to provide counselling services even outside working hours.

Hanning says: “This reality of erratic and unavailable services turns accessing mental health care into a lottery for survivors of sexual violence, one which can potentially lead to survivors taking their own lives.”

*Not her real name